Health Connections

For Physicians & Physician Assistants

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

Try to resolve open patient cases;

Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);

Send a letter to patients that have been seen within the past year notifying them of the practice closure;

Public Health Grand Rounds

All programs complement the clinical care of providers. By the end of the program, patients will have learned how to set goals to improve their health and lifestyle, manage their symptoms and medication, work with their health care team, talk with family and doctors, relax, eat well and handle difficult emotions. By gaining these skills, patients will become activated and engaged in their care. Healthcare providers will receive feedback on the status of any patient referrals.

Physicians and other healthcare providers who retire or stop practicing for other reasons should do their best to provide patients with continuity of care. When practices break up or separate, keep the patients’ interests first and foremost. The Rhode Island Board of Medical Licensure and Discipline frowns upon complaints that suggest physicians are fighting over patients or “using the patients” as part of the break up. Rhode Island law specifically requires that you:

Try to resolve open patient cases;

Publish a notice 90 days before closing a practice in a newspaper with statewide circulation, including information on how patients can get their medical records (when a physician is deceased, the heirs or the estate must give the same public notice within 90 days);

Send a letter to patients that have been seen within the past year notifying them of the practice closure;

The Rhode Island State-Supplied Vaccine program provides vaccine to healthcare providers to immunize people of all ages. A table with details about these vaccines, including their age indications, is available for healthcare providers.

Additionally, a series of immunization requirements are in place in Rhode Island to ensure that healthcare providers are properly immunized.

What you should do

Enroll in the State-Supplied Vaccine Program

Healthcare providers can enroll in the program to order vaccine for both pediatric and adult patients. Enrollment must be completed online annually.

Know about requirements

Before administering any vaccine, healthcare providers must give the current Vaccine Information Statement to patients (or their parents or guardians). This must be documented in the patient's medical record.

Know about patient eligibility

Influenza vaccine

Children: State-supplied influenza vaccine can be provided to all children (younger than 19 years of age), regardless of residence.

Adults: State-supplied influenza vaccine can be provided to all adult Rhode Island residents.

Medicare Fee-For-Service patients: Providers can use any state-supplied adult influenza vaccine for Medicare Fee-For-Service patients. (A Medicare Fee-For-Service patient is any patient whose services are billed directly to Medicare.) Providers will have to reimburse the Department of Health for doses administered to Medicare Fee-For-Service patients at the purchase price of the vaccine. Providers will be required to report weekly to the Department of Health on the products and quantities of vaccine administered to Medicare Fee-For-Service patients.

Non-influenza vaccine

Non-influenza state-supplied vaccine can be provided to all children (younger than 19 years of age). Adult, insured Rhode Island residents and adults who are non-Rhode Island residents but who are covered by a Rhode Island employer’s health plan are also eligible for non-influenza state-supplied vaccine if they are:

Medical Orders for Life Sustaining Treatment (MOLST)
are instructions to follow a terminally ill patient’s wishes regarding resuscitation, feeding tubes and other life-sustaining medical treatments. The MOLST form can be used to refuse or request treatments and are completely voluntary on the part of patients. These orders can supplement Do Not Resuscitate (DNR) instructions or a COMFORT ONE bracelet. more

A physician, registered nurse practitioner, advanced practice registered nurse or physician assistant who is authorized by the patient is authorized to sign Medical Orders for Life Sustaining Treatment.

Treat a patient in accordance with the patient's MOLST form, even if the healthcare provider who signed the MOLST order is not on staff at a facility.

Ensure a patient's Medical Orders for Life Sustaining Treatment are transferred with the patient if he/she is transferred to another healthcare provider.

If a new terminally ill patient comes under your care, you should ask about the existence of a MOLST form from the patient and/or the facility that is transferring the patient.

Review the Medical Orders for Life Sustaining Treatment on admission and ensure that the orders reflect the patient’s current wishes.

If the terminally ill patient does not have Medical Orders for Life Sustaining Treatment, you should offer them the opportunity to complete a form on admission to a nursing home, assisted living facility, home health agency, hospice program, kidney dialysis center, or hospital.

Document if a terminally ill patient does not file Medical Orders for Life Sustaining Treatment and explain the consequences of making no decision to the patient or their recognized healthcare decision maker. If there are no limitations on care, except as otherwise provided by law, cardiopulmonary resuscitation will be attempted and other treatments will be given. If a choice regarding cardiopulmonary resuscitation (CPR) is not made, cardiopulmonary resuscitation will be attempted using all available treatment options.

Void the Medical Orders for Life Sustaining Treatment if requested by your patient. To do this draw a diagonal line through the sheet, write “VOID” in large letters across the page, and sign and date below the line. Keep the voided MOLST form in the patient’s active or archived medical record, as appropriate.

Follow the most recent version of the Medical Orders for Life Sustaining Treatment if more than one form is found in the medical records.

What Medical Practices Should Do

Store patient’s medical records for at least five years after the most recent patient encounter, regardless of whether the patient is alive or dead. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. more

Provide copies when requested. Providers may charge a reasonable administrative fee for copying medical records; however, the transfer of medical records cannot be delayed due to non-payment of administrative fees. Records should be provided within 30 days.

Make sure that records are still available if the practice is closed.

Use Electronic Health Records which provide better way to see long term medical issues and track trends among groups of people. Healthcare providers who accept medicaid or medicare must meet "meaningful use" standards. more

Physicians Assistants work as part of a healthcare team, supervised by physicians following a written and signed agreement as required by law.
Sample Agreement
There are four mandatory elements of the agreement:

delineation of the level of supervision provided with particular reference to differing levels of supervision depending on the service being provided;

requirements for communication between the Physician Assistant and the supervising physician;

a job description for the Physician Assistant listing patient care responsibilities and procedures to be performed;

a program of quality assurance and periodic performance review

Clinical Supervision Oversight Criteria

The level of supervision and clinical oversight must consider the:

Potential for morbidity or mortality of a procedure; and

Level of experience of the Physician Assistant.

For example, a new graduate PA with limited experience performing an invasive procedure (e.g. insertion of a central venous line or a closed thoracotomy) may require on-site supervision / oversight for immediate consultation whereas adequate supervision of a PA with demonstrated competency in performance and management of possible complications of the same procedure may be provided by phone. Adequate supervision of the same new graduate PA working in a clinic or office setting providing basic primary care could be safely provided by phone.

Quality Assurance

As with overall supervision, the quality assurance program should reflect the experience level of the PA. Consideration should be given to evaluating the performance of the new graduate PA weekly initially. As the PA demonstrates the ability to meet the quality expectations of the supervising physician the evaluation interval may be increased but is required to be performed at least yearly. Accepted forms of performance evaluation include:

Monitor quit status through faxed QuitWorks feedback reports1)
Within weeks telling you that QuitWorks has spoken to your patient and if the patient consents to the counselling;2)
Within seven months telling you the patient's quit status;

If a patient relapses, re-evalutate and re-refer to QuitWorks when appropriate.

Continuing Medical Education (CME) opportunity: This CME event will provide information to healthcare providers so that they understand the latest trends in HIV and STDs, and that they can disrupt further spread of these infections by learning best practices for interacting with patients and their sexual partners. A special emphasis will be on current approaches to working with gay/bisexual men and other patients at highest risk of HIV and STDs. Participants will be provided with tools and resources to implement in their practices. This CME event will be held Thursday, April 30, 2015, from 5:15-7:30 pm at the Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI.

Hydrocodone, an opioid-type medication, will be reclassified as a Schedule II medication effective October 6, 2014. In the opinion of many regulators, patient advocates, and pain management experts, this change is long overdue.
Hydrocodone and all its combinations collectively represented the most popular pain medication prescribed in Rhode Island. Vicodin is a common brand name that contains hydrocodone. A review of 2013 data reveals there were more than 22.6 million doses filled. Schedule II medications have stricter regulation, reflective of the increased risk these medications have.
A summary of some of the rules surrounding all schedule II medications:
â€¢ The prescription must be written and signed by the prescriber.
â€¢ The prescription cannot have refills.
â€¢ The prescription is not valid after 90 days from the date it was written.
â€¢ A verbal prescription is allowed only in emergency situations and a written prescription must follow within seven days. (The pharmacist will notify the Drug Enforcement Agency if a written prescription is not received.)
â€¢ Faxed, original prescriptions are only allowed for:
o Home infusion/IV pain therapy
o Long-term-care facilities
o Hospice/terminally-ill patient
â€¢ Prescriptions have the following quantity limitations:
o 30-day supply
o Practitioners may write up to three separate prescriptions (each for up to a one-month supply) and each prescription must be signed and dated on the date they were originally written. In addition, the practitioner must write the earliest date each of those subsequent prescriptions may be filled, with directions to the pharmacist to fill no earlier than the date specified on the face of the prescription.
These are not all the rules surrounding hydrocodone and its varying combinations; however, prescribers will be responsible for following all of the rules when prescribing hydrocodone.
HEALTH urges all prescribers to plan for these changes that will take effect next week. It is likely this will have a significant impact on office practices as schedule II prescriptions cannot be phoned in to a pharmacy. HEALTH encourages e-Prescribing of Schedule II medications for safety and security.
The prescription drug abuse epidemic persists. All prescribers should consult HEALTH's website for expectations regarding responsible prescribing as well as enroll in and utilize the information found in the Prescription Monitoring Program before prescribing a controlled substance.

09/12/2014 16:48 EDT

HEALTH Alerts Physicians and Patients that Medications from Downing Labs LLC and NuVision Pharmacy Should Not Be Taken

The U.S. Food and Drug Administration is notifying health care professionals and consumers about safety concerns with all sterile-use drug products made and distributed by Downing Labs LLC, doing business as NuVision Pharmacy, in Dallas Texas. Because NuVision Pharmacy is licensed in Rhode Island as a non-resident compounding pharmacy, the Rhode Island Department of Health is alerting physicians and patients who may have received a product from Downing Labs LLC or NuVision Pharmacy that these medications should not be taken.
"We are exercising due diligence in respect to NuVision/Downing Labs. We are unaware of any immediate threat to Rhode Islanders but people should be aware if they have medication from NuVision/Downing Labs," said Michael Fine, MD, Director of the Rhode Island Department of Health. "NuVision Pharmacy has assured us that they will not ship any medication to Rhode Island until the issue is resolved with the FDA and that they have not shipped into Rhode Island since before January 2014."
Until further notice, health care professionals should not prescribe, administer or dispense any NuVision/Downing Labs sterile products for their patients because the firm cannot ensure the safety or quality of these products. Administration of a non-sterile drug product may result in serious and potentially life-threatening infection or death.
The FDA has issued a formal request to Downing Labs for the immediate recall of all lots of its purportedly sterile products currently on the market that are not expired. In the letter, the FDA outlined poor conditions and practices identified by FDA investigators during a July 2014 inspection of Downing Labs' Dallas facility. In the letter, the FDA outlined the practices and facility conditions that raise concerns about the sterility assurance of purportedly sterile drug products made at the Downing Labs facility.
"Patient safety is our top priority. We recommend health care professionals stop prescribing sterile drugs from Downing Labs because they pose serious potential risks to patients," said Janet Woodcock, M.D., director of the FDA's Center for Drug Evaluation and Research. "Patients deserve medications that are safe, effective, and of high quality no matter who makes them, and the FDA will continue to take action to protect patients."
The FDA's recent inspection of the Downing Labs facility in Texas revealed sterility failures in 19 lots of drug products intended to be sterile, endotoxin failures in three lots of drug products, and inadequate or no investigation of these failures. Endotoxins are substances found in certain bacteria that cause a wide variety of serious reactions such as fever, shock, and changes in blood pressure and in other circulatory functions.
On July 18, 2014, the FDA alerted health care professionals not to use purportedly sterile drugs from NuVision/Downing Labs due to possible contamination. On July 26, 2013, after observing poor conditions and practices during a March â€" April 2013 inspection, the FDA formally requested NuVision Pharmacy recall all sterile use drug products. The FDA reminds health care professionals to check their medical supplies, and quarantine any purportedly sterile drug products prepared at the Downing Labs/NuVision's facility, and not administer them to patients.
Products made at the Downing Labs facility are distributed nationwide. Most of the product labels include: NuVision Pharmacy, Dallas Texas 75244. 1-800-914-7435. Patients who have received any drug product produced at the Downing Labs/NuVision facility and have concerns should contact their health care professional and may contact the Rhode Island Department of Health at (401)-222-5960.
The FDA is not aware of recent reports of illness associated with the use of these products. The FDA asks health care providers and consumers to report adverse reactions or quality problems experienced with the use of any products made at the Downing Labs facility to the FDA's MedWatch Adverse Event Reporting program by:
Â· completing and submitting the report online [no longer operational 7/18/15]; or
Â· downloading and completing the form, then submitting it via fax to 1-800-FDA-0178.
The FDA, an agency within the U.S. Department of Health and Human Services, protects public health by assuring the safety, effectiveness, and security of human and veterinary drugs, vaccines and other biological products for human use, and medical devices. The agency also is responsible for the safety and security of our nation's food supply, cosmetics, dietary supplements, products that give off electronic radiation, and for regulating tobacco products.

Help us ensure that expecting parents have the most up-to-date information by providing them with the "What You Need to Know Before you Have Your Baby" brochure. This brochure introduces expecting moms and dads to the blood and hearing screenings their newborns will receive before they leave the hospital. It also provides information on KIDSNET and on support available to families through Rhode Island's First Connections home visiting program. The updated brochure should replace any earlier versions you may still have in your office.

Director of Health Michael Fine, M.D. announced today that influenza is no longer widespread in Rhode Island. Licensed healthcare facilities' healthcare workers who had not been vaccinated against influenza had been required to wear surgical masks when engaged in direct patient contact since April 17, 2014, when the Rhode Island Department of Health (HEALTH) declared influenza to be widespread. This requirement is no longer in place. However, if the level of influenza in Rhode Island rises again, HEALTH will put the masking requirement back into effect.

Director of Health Michael Fine, MD declared today that influenza is widespread again in Rhode Island. This declaration triggers the requirement that healthcare workers who have not been vaccinated against the flu wear surgical masks during direct patient contact. The masking requirement will stay in place until the declaration of widespread influenza has been lifted.

Infectious Disease News

Continuing Medical Education (CME) opportunity: This CME event will provide information to healthcare providers so that they understand the latest trends in HIV and STDs, and that they can disrupt further spread of these infections by learning best practices for interacting with patients and their sexual partners. A special emphasis will be on current approaches to working with gay/bisexual men and other patients at highest risk of HIV and STDs. Participants will be provided with tools and resources to implement in their practices. This CME event will be held Thursday, April 30, 2015, from 5:15-7:30 pm at the Warren Alpert Medical School of Brown University, 222 Richmond St., Providence, RI.

The New England TB Hero is an award presented each year by the New England Tuberculosis Consortium to recognize an extraordinary contribution to the care or management of patients with tuberculosis (TB) and latent tuberculosis infection (LTBI) or an activity that greatly enhanced TB prevention and control efforts in a locality or in a state. The individual recognized may be a member of the TB program or health department, a community clinic or hospital practitioner, or the lay community. He or she need not be a healthcare professional.
To nominate someone, complete the nomination form at the link above and attach a one page description of the nominee's contribution/ exceptional accomplishment(s) that make her or him a TB hero. The nomination should illustrate: the person's role in TB care, management, or activities; the specific qualities they have demonstrated that support their recognition; specific examples that demonstrate these qualities; and the impact that the activities had on the patient(s) or the community.
Please submit nomination forms by April 1, 2015 by email to jaime.comella@health.ri.gov. To submit by U.S. Postal Service, send to Jaime Comella, TB Program Manager, RI Department of Health, Three Capitol Hill, Room 106, Providence, RI 02908.

Director of Health Michael Fine, M.D. announced on Wednesday, March 4, 2015 that influenza is no longer widespread in Rhode Island.
Licensed healthcare facilities' healthcare workers who had not been vaccinated against influenza had been required to wear surgical masks when engaged in direct patient contact since December 30, 2014, when the Rhode Island Department of Health (HEALTH) declared influenza to be widespread. This requirement is no longer in place. However, if the level of influenza in Rhode Island rises again, HEALTH will put the masking requirement back into effect.

The United States is currently experiencing a large, multi-state outbreak of measles. Between January 1, 2015, and February 6, 2015, 121 cases from 17 states had been reported. One hundred three of these cases are linked to potential exposure at Disneyland Resort Theme Park in California. All Rhode Island healthcare providers should remain vigilant for possible measles cases. A single case of measles will trigger a full outbreak response.

Background: A 19-year-old Providence College (PC) student experienced the onset of symptoms of meningococcal meningitis on January 31 and was admitted to a Boston-area hospital. Tests confirmed that the student had meningococcal meningitis. The meningitis strain was reported to be serogroup B today. The student is recovering. A second, 20-year-old Providence College student was taken to a hospital yesterday (February 5) with purpura fulminans, altered mental status and nuchal rigidity thus meeting case definition criteria as a probable case of meningococcemia, pending lab confirmation. The two cases did not have any direct interaction with each other. Two cases occurring in this manner satisfy the CDC case criteria for an "organization-based" outbreak...

On Monday, Feb. 2, 2015, the Rhode Island Department of Health received a report of a confirmed case of meningococcal meningitis in a vaccinated Providence College student. The student was admitted to a Boston-area hospital and is reportedly improving.

Register by Jan. 9 for Free National Webinar: Molecular Diagnostics For Tuberculosis: What Are NAATs and How Do You Use Them?

CME Credit: This training is approved for up to 1.5 Category 1 ACCME continuing education hours/nursing education hours. This training is approved for up to 1.5 Category 1 ACCME continuing education hours/nursing education hours.
Target Audience: This training is intended for health care professionals who diagnose and treat tuberculosis. This training opportunity is available to a national audience.
Description: This 75-minute presentation will be followed by a 15-minute Q and A session. In recent years a number of rapid molecular diagnostics for detecting tuberculosis as well as drug resistance have become available both commercially and in public health labs. This webinar will describe the different NAATs (nucleic acid amplification tests) that are available to you, including the Gen-Probe MTD test, the Xpert MTB/RIF test, and Pyrosequencing (PSQ), as well as rapid molecular tests for drug resistance, including PSQ, line probe assays, and the CDC MDDR Service. We will describe what NAATs can and cannot tell you and how to best use these tests for AFB smear positive and smear negative clinical specimens. The webinar will also discuss the interpretation of specific mutations and drug resistance.

Immunization News

9-valent HPV vaccine (9vHPV) will be available for order through OSMOSSIS in July 2015.
Until July 2015, continue to order 4-valent HPV vaccine (4vHPV) only as needed. (This will help prevent vaccine wastage.)
Continue to vaccinate all patients using 4vHPV until 9vHPV is received.
Once practices have 9vHPV, they should continue to vaccinate males with their remaining 4vHPV until their 4vHPV inventories have been depleted.
Once 9vHPV is available, 4vHPV will no longer be available for order. However, practices will still be able to report doses of 4vHPV as administered in OSMOSSIS.

When vaccine providers enter returns into OSMOSSIS, they will now receive return labels via email from McKesson. (Previously, these slips had been sent via postal mail.) The labels will be sent to the email address that is associated with the practice's Vaccine Contact, as listed in OSMOSSIS.
Return labels will be emailed from uoltsupport@ups.com to the practice's Vaccine Contact. The message will have the subject line of "UPS Shipping API".
Return label emails will be sent during the first 5-business days of each month. If a label has not been received during the first 5-business days of the month (either in the Vaccine Contact's inbox or spam folder), contact the Rhode Island Department of Health (HEALTH)'s Office of Immunization (Viviana.Ciccia@health.ri.gov or Mark.Francesconi@health.ri.gov)
A return label will be provided for each 100 doses to be returned.
One return label will be included per e-mail (per 100 doses). Labels cannot be photocopied or reprinted. (If a practice is returning three boxes of vaccine, the Vaccine Contact will receive three emails, each containing one unique return mailing label.)
When sending several boxes in a single return, it does not matter which label is on which box. However, if all labels are not needed, put unused labels (along with the OSMOSSIS vaccine return packing slip) inside the package(s) being returned. These labels cannot be used for future returns.

05/15/2015 13:25 EDT

OSMOSSIS Return Packing Slips are now available for download/print

After receiving their vaccine return mailing labels, providers will be able to print vaccine return packing slips.
To print a vaccine return packing slip, log into OSMOSSIS and click the Generate Packing List link on the OSMOSSIS Vaccine Ordering Menu page. In the list of "Return Process Dates", select the one for the current month and click the "download/print" link on the top right corner. Make sure that only the products listed on the vaccine return packing slip are included in the box to be returned. Do not include products not listed on the packing slip in the box to be returned. Practices cannot write any product information on the vaccine return packing slip.

03/10/2015 10:20 EDT

Enrollment in the SSV program

Enrollment in Rhode Island's State-Supplied Vaccine (SSV) Program for 2015-2016 will open on June 1, 2015. Vaccine orders made after July 1, 2015 will not be processed until enrollment has been completed and certified. Healthcare providers will be required to pre-book influenza vaccine prior to July 1, 2015.
Healthcare providers can pre-book up to 120% of the doses they administered during the 2014-2015 influenza season.

12/23/2014 11:18 EST

Gardasil 9 and Gardasil Quadrivalent

The U.S. Food and Drug Administration recently approved Gardasil 9 (Human Papillomavirus 9-valent Vaccine, Recombinant) for the prevention of certain diseases caused by nine types of Human Papillomavirus (HPV). However, Gardasil 9 has not been approved by the Centers for Disease Control and Prevention (CDC)'s Advisory Committee on Immunization Practices (ACIP) and Gardasil 9 is not currently commercially available. Rhode Island healthcare providers should continue vaccinating patients against HPV with the currently available quadrivalent Gardasil vaccine. It is unknown when Gardasil 9 will become commercially available, so deferring vaccination in anticipation of its availability is discouraged. The Rhode Island Department of Health (HEALTH) will provide updates to healthcare providers about Gardasil 9 as they are made by the manufacturer and the CDC.